Hospice for Nursing Home Residents:Does Ownership Type Matter?

Maureen E. Canavan, PhD,1 Melissa D. Aldridge Carlson, PhD,2

Heather L. Sipsma, PhD,1 and Elizabeth H. Bradley, PhD1

Abstract

Background: Currently, more than half of all nursing home residents use hospice at some point. Studies haveshown benefits to hospice enrollment for patients; however, the literature on ownership differences in hospicecare in general has indicated that for-profit hospices offer a narrower scope of services and employ fewerprofessional staff. Although nursing home staffing patterns have been shown to be essential to quality of care,the literature has not explored differences in number of patients per staff member for hospice care within nursinghomes.Methods: We hypothesized that for-profit hospices would have a higher number of patients per staff member forhome care workers (HCWs), registered nurses (RNs), and medical social workers (MSWs), and this relationshipwould be moderated by the proportion of hospice users living in nursing homes. Using data from the NationalHospice Survey, a random sampling of all Medicare-certified hospices operating between September 2008 andNovember 2009, we identified 509 hospices that served individuals living in a nursing home, with 89 hospiceshaving 50% or greater of their clients living in a nursing home.Results: Adjusted analysis indicated a higher number of patients per staff member for HCWs and RNs amongfor-profit hospices. Moreover, compared with nonprofit hospices, for-profit hospices with a high proportion ofnursing home residents had 36 more patients per HCW ( p = 0.011) and 24 more patients per RN ( p = 0.033).Conclusions: Staffing is an important indicator of hospice quality, thus our findings may be useful for antici-pating potential impacts of the growth in for-profit hospice on nursing home residents.

Introduction

More than half of all nursing home residents nowuse hospice at some point while living in the nursing

home, a fourfold increase since 1992.1–2 Hospice patients areeligible for Medicare after they have been certified by twophysicians as having a life expectancy of 6 months or less.3

Studies have shown hospice to be associated with improvedsatisfaction with care among nursing home residents andbetter pain management.4–7 Despite evidence of advantagesfor residents, recent efforts by the Office of the InspectorGeneral (OIG)2 have addressed the concern that some hos-pices may be selectively enrolling beneficiaries who requireless complex but longer duration care.2 Hospices can restrictaccess to care for patients who do not agree to forego curativecare; however, they vary in the restrictiveness of their ad-missions policies.8–9 Given the per diem reimbursement sys-tem for hospice, enrolling less complicated, long-stay

individuals is financially advantageous for hospice organi-zations, and the OIG has noted that hospices with at least two-thirds of their clients in nursing homes are more likely to befor-profit hospices.2

Although previous research has examined differences innonprofit and for-profit hospices, this research has not fo-cused on differences within the nursing home setting. Evi-dence about nonprofit and for-profit hospices in general hasindicated that for-profit hospices provide a narrower scope ofservices10 and employ fewer professional staff.11 In particular,for-profit hospices have been shown to use fewer registerednurses (RNs) as a proportion of all nurses and use fewermedical social workers (MSWs) as a proportion of all coun-selors.12 Within nursing homes, studies have shown that re-ceiving hospice compared with not receiving hospice isassociated with higher quality of care5–7 and satisfaction13;however, these studies did not examine differences betweennonprofit and for-profit hospices delivering care in nursing

1Yale School of Public Health, Yale University, New Haven, Connecticut.2Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York.Accepted May 17, 2013.

JOURNAL OF PALLIATIVE MEDICINEVolume 16, Number 10, 2013ª Mary Ann Liebert, Inc.DOI: 10.1089/jpm.2012.0544

1221

homes. Specially, the literature has not explored differencesby ownership type in number of patients per staff member forhospice nursing home care, even though staffing patterns areessential to nursing home quality of care.14–15 Because nursinghome residents often have substantial functional and cogni-tive impairment, they may be particularly vulnerable tosuboptimal hospice care.

Accordingly, we sought to determine differences in staffingpatterns of for-profit and nonprofit hospices caring for nurs-ing home residents. Using data from the National HospiceSurvey, a cross-sectional national survey of Medicare-certifiedhospices,11 we estimated the association between hospiceownership type and reported staffing patterns. Based on fi-nancial incentives, we hypothesized that for-profit comparedwith nonprofit hospices would have a higher number of pa-tients per staff member for RNs, MSWs, and home healthaides. Additionally, we hypothesized that this relationshipcould be moderated by the proportion of hospice users re-siding in a nursing home for each individual hospice. Becausestaffing can be an important indicator of hospice quality, ourfindings can be useful for anticipating potential impacts of thegrowth in for-profit hospice on nursing home residents.

Methods

Study design and sample

We conducted a cross-sectional study using data from theNational Hospice Survey, conducted between September2008 and November 2009.11 The National Hospice Surveysample was selected randomly from all Medicare certifiedhospices included in the 2006 Medicare Provider of Services(POS) file. To incorporate newly operational hospices, theNational Hospice Survey sample also included randomly se-lected hospices that had been operational for 2 years or lessfrom the 2008 Medicare POS file. A more detailed account ofthe sampling methodology used to create this dataset is de-scribed in an earlier publication.11 A total of 914 hospices werecontacted for participation (775 hospices obtained from the2006 POS file and 139 newly operating hospices obtainedfrom the 2008 POS file); 208 (23%) were excluded because thefacility was either closed or no longer providing hospice care.Of the remaining 706 hospices, 591 hospices (84%) had thestaff member most knowledgeable about the survey questionscomplete the web-based survey. Data from each survey werecombined with the information from the 2008 Medicare POSfile by hospice ID for analysis. We limited the sample for thecurrent analysis to include only hospices that reported treat-ing any nursing home residents, for a total sample size of 509hospices. Within this sample, 89 hospices treated primarilynursing home residents (defined as having more than 50% ofpatients residing in the nursing home) and were used toconduct subgroup analyses.

Measures

The primary dependents variables were the average num-ber of patients per staff member for each staff type. The surveyquestions asked, ‘‘Please estimate the number of patients perday your hospice cared for during a typical day in the past 12months in nursing home setting’’ and the number of full-time(staff type) employed over the past 12 months. We calculatedthe number of hospice users per staff member for RNs, MSWs,

and home care workers (HCWs). We constructed each valueby dividing the hospice’s response for the average number ofpatients served per day over the past year by the averagenumber of full-time equivalent RNs, MSWs, and HCWs em-ployed over the past 12 months, respectively.

Our primary independent variable was hospice ownershiptype, which was self-reported by the hospice and classified asfor-profit, government, or nonprofit. Additional covariates in-cluded hospice size (average number of patients served perday), years in operation since Medicare certification (0–9 yearsand ‡ 10 years), census geographic region (New England,Middle Atlantic, East North Central, West North Central,South Atlantic, East South Central, West South Central,Mountain, and Pacific), and proportion of hospice users re-siding in a nursing home (the average number of hospice usersliving in a nursing home per day over the past 12 monthsdivided by the total average number of hospice users per dayover the past 12 months). Additionally, we created a binaryvariable representing ‡ 50% of hospice users residing in anursing home (equal to 1) and 0 if the proportion was < 50%.

Statistical analysis

We used standard descriptive statistics to describe oursample of hospices and the distribution of our outcome vari-ables. We then used t tests and analyses of variance (ANOVA)sto estimate the unadjusted associations between hospiceorganizational characteristics (ownership type, hospice size,years in operation since Medicare certification, proportion ofhospice users residing in a nursing home, and census geo-graphic region) and our staff-related outcomes (numbers ofpatients per staff member for each type of hospice staff ). Weused multivariable linear regression models to estimate theadjusted associations between hospice organizational char-acteristics and our staff-related outcome measures. Ad-ditionally, because we hypothesized that the proportion ofhospice users residing in a nursing home could moderate theassociation between ownership type and staffing, we testedthis moderation by including in our multivariate model theinteraction between ownership type and proportion of hos-pice users residing in a nursing home as a continuous variableand categorical variable with a cut point at 50%. We alsoperformed subgroup analysis among hospices that had atleast 50% of their users residing in nursing homes. All ana-lyses were performed using SAS software, version 9.2 (SASInstitute, Cary, NC).

Results

Study population and sample characteristics

Within our sample, approximately 7% of hospices had atleast 2 out of 3 of their patients in nursing homes and anadditional 11% of the overall sample (n = 89 hospices) had atleast half of their users residing in nursing homes. A total of51% of hospices in our sample had at least one-quarter of theirusers residing in nursing homes. Survey response rates didnot differ significantly by hospice geographic region, yearssince Medicare certification, or size, although for-profit hos-pices were significantly less likely to respond, as has beenpreviously reported.11

Sample characteristics of the 509 hospices that servednursing home residents are shown in Table 1. The sample was

1222 CANAVAN ET AL.

evenly distributed between for-profit and nonprofit ownershiptype. On average, hospices served approximately 94 (standarddeviation [SD] 179.9) individuals per day. Nearly 42% of hos-pices had been operating for less than 10 years. Overall, ap-proximately 30% of hospice users resided in nursing homes.The mean number of patients per hospice HCW was 15 pa-tients (SD 44.3); the mean number of patients per hospice RNwas 8 (SD 26.9) patients; and the mean number of patients perhospice MSW was 22 (SD 57.6) patients.

Staffing patterns

In unadjusted analysis (data not shown), for-profit hospiceshad more than twice as many patients per HCW comparedwith nonprofit hospices ( p value of 0.009). For-profit com-pared with nonprofit hospices also had more patients per RNand MSW, but these differences were not significant (p valuesof 0.081 and 0.114, respectively). Hospice size was signifi-cantly associated with a higher number of patients per staffmember for HCWs, RNs, and MSWs ( p values of 0.005, 0.023,and < 0.001, respectively). Years in operation since Medicarecertification was significantly associated with the number ofpatients per HCW, with younger organizations having ahigher number of patients per HCW ( p value of 0.043);however, years since Medicare certification was not signifi-cantly associated with the number of patients per RN or perMSW ( p values of > 0.10). Geographic region was not sig-nificantly associated with the number of patients per staffmember for any staff type ( p values of > 0.05).

Stratifying by having at least 50% of hospice users living ina nursing home exhibits a difference in the breakdown of

patient per staff type by ownership type (Fig. 1). Amonghospices that had 50% or more of their users residing innursing homes, there was a significantly higher number ofpatient per staff type for HCWs and RNs ( p values of 0.003and 0.007, respectively) but not for medical social workers ( pvalue of 0.439). The difference in ownership type was not seenfor HCWs, RNs, or MSWs in hospices with less than half oftheir users residing in nursing homes ( p values of > 0.05).

In analysis adjusted for geographic region, hospice size,and years in operation since receiving Medicare certification,the association between ownership type and number of pa-tients per staff member remained significant for HCWs andbecame significant for RNs (Table 2). Compared with non-profit hospices, for-profit hospices had 16 additional patientsper each HCW ( p value of 0.002) and 6 additional patients pereach RN ( p value of 0.036). Hospice size was also significantlyassociated with the numbers of patients per HCW, per RN,and per MSW ( p values of 0.004, < 0.001, and < 0.001, re-spectively) with larger hospices having more patients pereach staff type. We also tested for a moderating effect of sizeon the relationship between ownership type and patientsper staff member; however, because this effect was not sig-nificant it is not presented or included in models. Neither thenumber of years in operation since Medicare certification norgeographical region was significantly associated (p valuesof > 0.05) with the number of patients per staff member in theadjusted analysis. Building upon our main effects analysis, wefound that the association between ownership type on num-ber of patient per staff member was significantly moderatedby proportion of nursing home residents for HCWs and forRNs ( p values for interaction terms of 0.040 and 0.003, re-spectively).

Subgroup analysis

Among the sample of hospices that had 50% or greater oftheir users residing in a nursing home (n = 89), for-profithospices had 36 more patients per HCW ( p value of 0.011) and24 more patients per RN ( p value of 0.033) compared withnonprofit hospices (Table 3). Among hospices that had lessthan 50% of their users residing in a nursing home (n = 420),for-profit hospices had 11 more patients per HCW and onemore patients per RN ( p values of 0.048 and 0.653, respec-tively) compared with nonprofit hospices.

Discussion

We found distinct differences by hospice ownership type instaffing patterns, particularly for HCWs and RNs. The mag-nitude of the associations was large, with for-profit hospiceson average having 15 more patients per HCW and 5 morepatients per RN than nonprofit hospices. The relationship wasapparent among the full sample of hospices but was partic-ularly pronounced among hospices that had more than 50% oftheir patients residing in nursing homes. Reports by the Officeof Inspector General (OIG)2 have highlighted concerns abouthospices that predominately care for nursing home residents,noting that these are for the most part for-profit hospices andmay have opportunities to provide less complex care over alonger duration. Nevertheless, ours is the first study of whichwe know that has examined, among a national sample ofhospices, the role of ownership on staffing patterns for hos-pices serving nursing home residents.

Table 1. Characteristics of Hospices That Serve

Nursing Home Residents (n = 509 facilities)

N Percentage

Hospice ownershipNonprofit 257 50.5For-profit 236 46.4Government 16 3.1

RegionNew England 24 4.7Middle Atlantic 37 7.3East North Central 84 16.5West North Central 68 13.4South Atlantic 75 14.7East South Central 45 8.8West South Central 92 18.1Mountain 41 8.1Pacific 43 8.5

Years in operation since Medicare certification0–9 years 206 40.5‡ 10 years 303 59.5

Proportion of hospice users residing in nursing home< 0.50 420 82.5‡ 0.50 89 17.5

Mean SDHospice size (patients per day) 93.5 179.9Number of patients per staff member

Patients per registered nurse 8.1 26.9Patients per medical social worker 22.0 57.6Patients per home care worker 14.8 44.3

HOSPICE OWNERSHIP TYPE IN NURSING HOMES 1223

Previous literature has demonstrated the substantial valueof hospice care within nursing homes. Hospice presence innursing homes has been linked to increased pain manage-ment6–7 and lower rates of hospitalization in the last 30 daysof life.5 Moreover, nursing homes that offered hospice serviceswere more likely to have special programs and trained stafffor hospice or palliative care,16 and these were also linkedwith higher likelihood of having special programs for mentalhealth services.16

Nevertheless, this literature had not examined differencesin for-profit and nonprofit hospices care in the nursing home

setting. Our study suggests that, despite the overall benefits ofhospice in the context of nursing homes, hospices differ intheir approaches with for-profit hospices using fewer staff fortheir patient populations compared with nonprofit hospices.

The recent OIG report expressed concerns about hospicestargeting the nursing home environment because of the po-tential for increased profits.2 Nursing home residents tend tohave less invasive care needs but require a longer duration ofcare; additionally, the current Medicare reimbursement sys-tem pays an identical rate for care regardless of the location ordaily services provided, which have both been linked to

FIG. 1. Average number of hospice patients per staff type by percentage of users residing in nursing homes for for-profitand nonprofit hospices.

Table 2. Multivariable Linear Regression Models Examining the Number 0f Patients per Hospice Staff

Member Overall and by Hospice Characteristics (n = 509 facilities)

Patients per home care worker Patients per registered nurse Patients per medical social worker

b(SE) P value b(SE) P value b(SE) P value

Hospice ownershipNonprofit Reference Reference ReferenceFor-profit 15.6 (4.92) 0.002 6.4 (3.02) 0.036 12.0 (6.24) 0.055Government 5.4 (11.33) 0.636 - 2.3 (6.96) 0.737 3.3 (14.39) 0.817

RegionNew England Reference Reference ReferenceMiddle Atlantic 6.8 (11.38) 0.550 - 1.2 (6.99) 0.860 - 2.2 (14.45) 0.879East North Central 2.9 (10.07) 0.771 7.8 (6.18) 0.209 13.5 (12.78) 0.290West North Central 5.9 (10.30) 0.565 6.8 (6.33) 0.281 13.1 (13.08) 0.318South Atlantic - 6.6 (10.30) 0.522 - 1.5(6.32) 0.815 - 4.3 (13.07) 0.745East South Central - 16.1 (11.07) 0.147 - 4.1 (6.80) 0.547 - 15.8 (14.06) 0.261West South Central - 10.3 (10.09) 0.306 0.8(6.20) 0.895 - 0.8 (12.81) 0.949Mountain - 18.2 (11.22) 0.105 - 5.2 (6.89) 0.450 - 16.3 (14.25) 0.254Pacific - 5.9 (11.10) 0.594 - 4.3 (6.81) 0.524 - 14.2 (14.08) 0.314

Years in operation since Medicare certification0–9 years Reference Reference Reference‡ 10 years - 5.7 (4.89) 0.244 - 2.1 (3.00) 0.488 - 11.0 (6.20) 0.076

Hospice size (patients per day) 0.1 (0.01) < 0.001 0.1 (0.01) 0.004 0.1 (0.01) < 0.001

1224 CANAVAN ET AL.

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increased profit margins.2 Moreover, since 2005, Medicarespending on hospice care based in nursing homes has grownnearly 70%, and the majority of these hospices primarilyserving nursing home residents have been for-profit.2 Ouranalysis adds to the expressed concerns as for-profit hospicesmay employ fewer staff per patient. Currently, the require-ments for the Medicare Certificate of Participation for hos-pices does not address specific staffing requirements,although patient-to-staff ratios exist as part of hospice licen-sure regulations in some states. Our study indicates that for-profit hospices tend to have more patients per staff member,which could lead to lower quality of care.

Our findings should be interpreted in light of several lim-itations. First, we cannot evaluate whether a higher number ofpatients per staff member result in poorer quality of care. Itmay be that for-profit hospices are more efficient in their useof staffing without compromising quality, that their nursinghome-hospice contracts allow for more care to be provided byexisting nursing home staff or that they have invested in bettertechnology for delivering services. The only data we have ontechnology is the use of an electronic medical record, whichwas significantly more likely among nonprofit than for-profithospices. Second, our study is limited by the potential forresponse rate bias because for-profit hospices were less likelythan nonprofit hospices to respond; the direction of this bias isunclear. Additionally, because our data were collected at thehospice level, we only had access to the overall number ofpatients per staff member and were not able to directly esti-mate the number of patients per staff member providing careto nursing home residents, nor were we able to determine ifpatient-level health outcomes were affected by staffing dif-ferences. Although we assumed these ratios were equivalent,it is possible that they could differ. In this analysis we wereonly able to assess the number of staff and did not havemeasures of their skill-level or capacity, which would bevaluable for interpreting the observed differences. Last, welacked specific data on services offered by each facility andpatient-level data on services received or health status. Futurestudies are warranted to explore more comprehensive mea-sures of staffing quality within hospice care and its associationwith patient-level health measures.

With the marked increase in the proportion of for-profithospices, identifying differences in ownership type may havefar-reaching implications. Our data demonstrated that for-profit ownership was associated with a significantly highernumber of patients per HCWs and per RNs. Staffing repre-sents a critical element of hospice care and thus serves animportant role in measuring quality. Future studies are nee-ded to examine if differences in staffing patterns by owner-ship type are linked to measures of quality of care and patientand family satisfaction.

Acknowledgments

This study was supported by grant 1R01CA116398-01A2from the National Cancer Institute (Bradley) and grant1K99NR010495-01 from the National Institute of NursingResearch (Aldridge-Carlson).

Author contributions: MEC, EB: study concept and design;MEC, MDAC: acquisition of subjects and/or data, analysisand interpretation of data; MEC, MDAC, HLS, EB: prepara-tion of manuscript.

Author Disclosure Statement

No competing financial interests exist.

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4. Miller SC, Gozalo P, Mor V: Outcomes and utilization forhospice and non-hospice nursing home facility decendents.Office of Disability, Aging and Long-Term Care Policy inthe Office of the Assistant Secretary for Planning andEvaluation. US Department of Health and Human Services,2000.

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6. Miller SC, Mor V, Wu N, Gozalo PL, Lapane K: Does receiptof hospice care in nursing homes improve the managementof pain at the end of life? J Am Geriatr Soc 2002;50:507–515.

7. Miller SC, Mor V, Teno J: Hospice enrollment and pain as-sessment and management in nursing homes. J PainSymptom Manage 2003;26:791–799.

8. Lorenz KA, Asch SM, Rosenfeld KE, Liu H, Ettner SL:Hospice admission practices: Where does hospice fit in thecontinuum of care? J Am Geriatr Soc 2004;52:725–730.

9. Aldridge-Carlson MD, Barry CL, Cherlin EJ, McCorkle R,Bradley EH: Hospices’ enrollment policies may contribute tounderuse of hospice care in the United States. Health Affairs2012;12:2690–2698.

10. Aldridge-Carlson MD, Gallo WT, Bradley EH: Ownershipstatus and patterns of care in hospice. Med Care 2004;42:432–438.

11. Aldridge-Carlson MD, Barry CL, Schlesinger M, et al.:Quality of palliative care at US hospices: Results of a na-tional survey. Med Care 2011;49:803–809.

12. Cherlin EJ, Aldridge-Carlson MD, Herrin J, et al.: Inter-disciplinary staffing patterns: Do for-profit and nonprofithospice differ? J Palliat Med 2010;13:389–394.

13. Wetle T, Teno J, Shield R, Welch L, Miller SC: End of life innursing homes: Experiences and policy recommendations.Washington,DC: The AARP Public Policy Institute, 2004.

14. Zheng NT, Temkin-Greener, H: End-of-life care in nursinghomes: The importance of CNA staff communication. J AmMed Dir Assoc 2010;11:494–499.

15. Castle NG, Engberg J: Turnover and quality in nursinghomes. Med Care 2005;43:616–626.

16. Miller SC, Han B: End-of-life care in US nursing homes:Nursing homes with special programs and trained staff forhospice or palliative/end-of-life care. J Palliat Med2008;11:866–877.

Address correspondence to:Maureen E. Canavan, PhD

2 Church Street South, Suite 409New Haven, CT 06519

E-mail: Maureen.canavan@yale.edu

1226 CANAVAN ET AL.